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tuberculosis in which we have associated early pleural adherency, however slight, are prone to develop bronchiectasis under certain conditions.”

Referring to lesions of the bronchi alone, the writer states that the sequence of events is bronchitis, peri-bronchitis, possibly chronic interstitial changes, then cough, with increased air pressure and emphysema. Here there is no associated pleural adherency.In some few cases the bronchioles may dilate, and there is then slight pleural adherency.

Changes in the pleura alone are next discussed, and it is stated that bronchiectasis, saccular in character, may follow upon pleurisy with effusion. In these cases the lung is generally very much fibrosed. The writer states his inability to determine the part played by the pleural adhesion in such

The author remarked that the root glands of the lung were enlarged in his cases of bronchiectasis, and he concludes that there is some connection between the two conditions, and suggests that the course of events is : bronchitis, absorption by the glands from the bronchi, enlargement of the glands, stagnation in the lymph channels, vicarious action of the sub-pleural lymphatics, and stagnation in these latter, leading to chronic pleuritis, and then to adhesion, and, as a remote result, the bronchi may dilate.

In speaking of pulmonary fibrosis, the writer does not subscribe to the view expressed by Corrigan and others that this may arise from pleuritis, and subsequently by contraction dilate the bronchi. He believes such fibrosis to be independent of the pleural lesion, and therefore not the cause of bronchiectasis. He admits that, given dilatation of the tubes, pulmonary fibrosis may tend to increase it.

The author's conclusions are, therefore :-(1) Pleural adherency, however slight, occurring either locally or generally, is a factor of marked importance in the initial production of bronchiectasis, chiefly through the support which it thus gives to the lung tissue during continuous expiratory effort with closed glottis, especially when associated with diminished inspiratory effort.

(2) Pleural adherency alone, especially when the pleura is thickened, leads to a greater diffusion of the air pressure away from the terminal parts of the respiratory tracts, and so tends to a greater degree of dilatation of the larger tubes.

In some cases, where the bronchiectasis is of the saccular variety, with associated cylindrical dilatation higher up the same tube, there was marked adherency, with marked thickening of the pleura ; and in other cases, with purely saccular dilatations, the pleura was only slightly adherent or non-adherent.”

DOUGLAS STANLEY, M.D.

PERFORATION OF THE STOMACH BY ULCER.

By F. AND G. GROSS.

An interesting and most exhaustive paper has been running through the Revue de Chirurgie, from February to August, on this subject by the above authors, containing not only a review of the subject up to date, but practically summarising the published writings and statistics thereof. The preamble, so to speak, lies in two cases which came under their care.

The first was a woman of twenty-nine, with three weeks' history of pain after food, with vomiting ; no hæmatemesis; then a sudden attack of intense pain in abdomen in morning; better towards evening, but vomiting ; constipation. She had a good night, but general condition worse next day. The third day she walked to hospital, over three miles, where she was found to be in the following condition :-Slightly anxious expression of face; pulse, 80; temperature not raised; respirations short and thoracic in type; abdomen somewhat distended, and rather rigid ; epigastric region more distended than other parts ; tympanitis all over abdomen ; liver dulness decreased; some prehepatic tympanitis; no dulness in flanks perceptible. A diagnosis was made of either appendicitis or intestinal obstruction.

Next day, the patient being worse, a laparotomy was performed in median line below umbilicus. Gas escaped when peritoneum was incised; a greenish flaky lymph covered the coils of

intestine. Appendix examined and found healthy, Incision prolonged upwards ; disclosed a perforation of gastric ulcer, size of a florin, situated on the anterior surface of stomach near pylorus. This was closed with Lembert's sutures, peritoneum sponged out, adbomen drained, and wound closed. Patient died next day. Bacteriological examination of peritoneal exudate showed (1) an encapsulated diplococcus, the streptococcus of Escherich--a diplococcus on solid media, chains in liquid media ; (2) a short bacillus, (3) blasto-mycetes (2 and 3 both frequent in stomach).

The second case, male, aged forty-seven, had strong history of chronic alcoholism ; two years' history of stomach trouble, with attacks of severe pain after food ; had very violent attack of epigastric pain when on journey to surgeon, whom he saw two hours afterwards. One hour after this was operated upon, i.e., three hours after attack, and perforated gastric ulcer found and stitched. Patient recovered after a violent attack of delirium tremens.

The frequency of gastric ulcer is variously estimated.

Post Mortem Records Estimating Frequency of Ulcer.Gluzinski, in 11,298 autopsies, found 8.4 per thousand, equal to 0.84 per cent. Stadwell, in 7,700 cases, 1.24 per cent. F. Brunner estimates proportion of females to males as four to one.

The frequency of perforation, as well as the frequency of ulcer, appears to be increasing, and is also variously estimated :-Leube, 1 per cent. ; Broadbent, 6 per cent. ; Greenhaugh, 3 per cent. ; Brinton, 13 per cent. ; Habershon, 18 per cent. ; Pearce Gould, 25 per cent. ; Michaux, 3 to 5 per cent.

History of operative interference is interesting. Mickulicz closed the first in 1880 by suture. In England, 1887, Taylor recorded first suture; and from this to 1893, Barlett, Lockwood, Barling, Haslam, Haward ; but all were unsuccessful. The first success was in 1893 in England, 1892 in Germany. Kriege collected eight cases in 1892, with no

After this, successes came thick and fast, and in

success.

1895 Parisier collected forty-three cases, with ten cures; and in 1896, ninety-nine cases, with thirty-three cures. Bidwell, in 1900, 414 cases, with 139 cures.

The site of the ulcer is shown most completely by F. Brunner, with 320 cases—278 anterior, 42 posterior. In those cases in which position of ulcer is indicated, the large majority-about eight to one-are nearer lesser curvature, but in an equal number of cases the exact position is not indicated. Cardiac portion more frequently than pyloric 5:3.

The large number of anterior perforations is accounted for by several reasons :-(1) Mobility of the anterior stomach wall and its movement on anterior abdominal wall; (2) thus easily influenced by traumatism ; (3) little tendency to contract adhesions on account of mobility. In the case of posterior wall, less vitality, more adhesions, and more tendency to localisation and formation of a subphrenic abscess ; thus onset of case is slower, and there is less immediate danger.

Characters of Perforating Ulcer.-Round or oval. Borders but rarely irregular. Borders generally indurated, and rarely wanting in this respect, the induration sometimes amounting to a tumour easily mistaken for malignant disease. The size is generally about three-eighths of an inch in diameter, sometimes reaching to three-quarters or one inch. Very occasionally the perforation is almost imperceptible, and may be even undiscoverable where it has set up fatal peritonitis. Barker mentions a case where pus was present from perforating ulcer, but perforation could not be found ; and put forward the hypothesis that a small perforation had allowed the passage of the colon bacillus, which had thereupon set up formation of gas, while the hole itself rapidly cicatrised. Occasionally the hole is masked and closed in by a fibrinous exudate.

Multiple perforations are rare, but there are reported cases, though multiple ulcers are not at all uncommon. Brinton collected ninety-seven cases of multiple ulcers out of 463. Of these, fifty-seven had two ulcers; sixteen had three; three had four; two had five ; four had more than five ulcers.

Several cases are recorded of operation upon and closure of one ulcer, and post mortem another ulcer found. In one case, second ulcer perforated three weeks later; in another case there were three perforations.

Consequences of perforation depend upon the point of perforation, the state of the stomach, whether fasting or full, the state of the gastric contents, etc.

Gas, as mentioned before, sometimes without being able to find perforation, may be inodorous or of a sour stomachlike odour; at other times is fætid, and smelling of bacilli coli. Gruneison, Barker, and others are of opinion that there may be gas without perforation, owing to production by gas forming bacilli coli passing through thin wall of ulcer, Umber calls it the bacillus paracoli ærogenes.

During the first few hours the escaped contents of the stomach are unchanged, and may be recognised as milk, coffee, etc., but, setting up a peritonitis, this is rapidly diluted and hidden by the peritoneal exudate. During the early part of the first twenty-four hours, the signs depend upon the virulence of stomach contents and amount of gastric contents at the time of perforation. Thus, if a small perforation and contents of stomach are not great in amount, and not very virulent, the result may be the formation of a perigastric abscess, as in posterior perforations. Another point, too, is the position and occupation of the patient at the time. Thus, if standing at work, the escaped contents are spread all over the abdomen, and a general peritonitis is at once set up. But if lying in bed, there is more liability to localisation, or to the fluid finding its way to the most dependent parts, the flanks, Douglas's pouch, subdiaphragmatic spaces.

This is insisted upon by Gerulanos, who describes a case of a girl of twenty-one, who perforated and had all the signs of general infection, with profound collapse, contra-indicating operation. Three weeks later he opened a lumbar abscess, and a collection in Douglas's pouch ; and on the fortieth day, a subdiaphragmatic abscess, after which she recovered.

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